How should a patient with HFpEF, hypertension, moderate AS and AR, moderate MV regurgitation, DMT2, and history of asymptomatic TIA minor and PA disease be managed on current medications including Dapagliflozin, Telmisartan, and Metformin?

Management of a Patient with HFpEF, Hypertension, Valvular Disease, DMT2, and History of TIA and PA

The optimal management for this complex cardiovascular patient should include optimizing current medications (increasing telmisartan dose), adding a beta-blocker, considering an MRA, and maintaining dapagliflozin therapy, while closely monitoring blood pressure and valvular disease progression. 1

Current Medication Assessment

• Dapagliflozin (10mg) is appropriate and should be continued as it has demonstrated significant benefits in HFpEF patients by reducing the risk of cardiovascular death, hospitalization for heart failure, and urgent heart failure visits 2, 3
• Telmisartan (40mg) is likely underdosed for a patient with average BP of 150/80 mmHg; current guidelines recommend adequate blood pressure control in HFpEF patients to improve filling pressures and promote regression of hypertrophy 1
• Metformin (500mg) is appropriate as baseline therapy for DMT2 and can be safely continued alongside the other medications 1

Recommended Medication Adjustments

Blood Pressure Management

• Increase telmisartan to 80mg daily to achieve better blood pressure control, as current BP of 150/80 exceeds recommended targets for patients with cardiovascular disease 1, 4
• Add a beta-blocker (preferably bisoprolol, carvedilol, or metoprolol succinate) which is reasonable for HFpEF patients with hypertension and would also help manage the moderate valvular regurgitation 1
• For HFpEF patients with hypertension, the 2016 AHA guidelines suggest that beta-blockers, ACE inhibitors, and ARBs are reasonable to control BP 1

Heart Failure Management

• Consider adding a mineralocorticoid receptor antagonist (MRA) such as spironolactone, which may benefit patients with HFpEF, especially those with elevated natriuretic peptide levels 1
• Continue dapagliflozin 10mg daily, which has shown significant benefits in reducing cardiovascular death and heart failure hospitalizations in HFpEF patients regardless of diabetes status 2, 3, 5
• Recent evidence from the DELIVER trial shows dapagliflozin provides consistent benefits in HFpEF patients regardless of background beta-blocker use 6

Valvular Disease Considerations

• The moderate aortic stenosis/regurgitation and mitral regurgitation require regular echocardiographic monitoring (every 6-12 months) 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to their negative inotropic effects which could worsen heart failure symptoms in the context of valvular disease 1, 7

Management of Comorbidities

• For the history of TIA and peripheral artery disease, consider adding low-dose aspirin (75-160mg daily) if not contraindicated 1
• Dapagliflozin has shown consistent benefits for cardiovascular and kidney outcomes in patients with and without peripheral artery disease, with no significant increase in limb-related adverse events 8

Monitoring Recommendations

• Monitor blood pressure regularly, aiming for a target of <130/80 mmHg 1, 7
• Schedule regular echocardiographic follow-up (every 6-12 months) to assess valvular disease progression 1
• Monitor renal function and electrolytes, particularly after medication adjustments 1, 2
• Assess for signs of fluid overload and adjust diuretic therapy as needed 1
• Monitor for symptoms of heart failure exacerbation, particularly with the moderate valvular disease 1

Potential Pitfalls and Cautions

• Avoid hydralazine monotherapy as it may provoke myocardial ischemia, though hydralazine-isosorbide dinitrate combination could be considered if the patient becomes intolerant to ARB therapy 9
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) which are contraindicated in heart failure 1
• Avoid alpha-blockers like doxazosin which have been associated with increased risk of developing heart failure 1
• Be cautious with high-dose diuretics which may worsen renal function; consider sequential nephron blockade if diuretic resistance develops 1
• Monitor for potential drug interactions, particularly between the cardiovascular and diabetes medications 1